Can India Achieve the SDG Goal on Ensuring Health and Well-being?

Between July 10th-19th, country representatives from all over the globe congregated in New York for the High Level Political Forum Meeting of the Sustainable Development Goals (SDGs) to report on their respective progress towards the Goals, and renew their commitments to the same. The SDGs which were announced in 2016, have created new opportunities around development practice and policies, both in the non-profit sector as well as in policy making in India. In keeping with this commitment, India too participated in this voluntary review and presented the efforts that the government has made. A report[1] on how the Government of India has addressed specific Goals (Goal 1 – Poverty, Goal 2 – Hunger, Goal 3 – Health, Goal 5 – Gender Equality, Goal 9 – Industry, Goal 14 – Life below water and Goal 17 – Global Partnerships) was prepared by the NITI Aayog. The report ‘ Voluntary National Review (VNR) Report on the Implementation of Sustainable Development Goals’ describes the Government of India’s efforts to align its policies with the new global agenda. The VNR report states that India has made significant strides in improving various health indicators. It cites the increase in institutional deliveries, decline in Infant Mortality Rate and Under-5 Mortality Rate and improvement in vaccination coverage for children between 2005-06 and 2015-16, to substantiate these claims. It also describes other efforts such as the development of a composite index to monitor and incentivise improvements in health service delivery and ways in which information technology is being applied in the health sector.

In keeping with its commitment to the SDG agenda, the government has passed several policies and schemes in alignment with the SDG health targets, which have been detailed out in the GoI’s report.The National Health Policy 2017for example addresses several of the Goal 3 targets including communicable and non-communicable diseases, health workforce and universal health coverage. Since the commencement of the SDGs, the government has also passed legislation specifically around Mental Health (Mental Health Care Act, 2017), Disabilities (Rights of Persons with Disabilities Act 2017), HIV /AIDS (Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome Prevention and Control Bill, 2017) and maternity benefits (Maternity Benefits Amendment Act 2017). In March 2017, the Ministry of Statistics Planning and Implementation (MOSPI) also evolved national indicators for the SDGs, in accordance with the global indicators.

Despite the passage of these legislations and policies, and the claims of the government in its report, we would like to highlight some fundamental concerns related to the functioning of the health system and implementation of policies and programmes, as well as the adequacy and reliability of set indicators to monitor progress towards SDG Goal 3.

Financial commitments: Currently, health financing in India is characterised by over dependence on household out-of-pocket payments (OOPs) and consequent lack of financial protection. It is worth noting that annually 55 million people in India are pushed into poverty just to cover health expenses (2011).[2]Global experiences suggest that India’s quest for universal health coverage (UHC) cannot be realised unless public spending is expanded significantly, at least to the level of comparable developing countries. For instance, every other BRICS country government spends more than three percent of GDP on health, while India is hovering around 1.15%.[3]Unfortunately, neither global nor national SDG indicators talk about increasing public spending on health to a certain desirable level. The National Health Policy 2017envisages an increase in spending to 2.5% of the GDP by 2025, which is far too little and too delayed.Meanwhile, contrary to the stated commitment in the NHP, the Union government has been consistently cutting back on the health budget; what has been allocated for 2017-18 is even lesser than the expenditure for the year 2011-12, when adjusted for inflation.[4]

Health system strengthening: As of 2015, Rural Health Statistics (2014-15) indicate that there is still a shortfall in the required number of Sub-Centres, Primary Health Centres and Community Health Centres, despite the investments in NRHM over more than a decade. Similarly, there is a shortfall of human resources, particularly specialists in rural areas. These deficiencies have seriously hampered improvement of health outcomes. For instance, even though the proportion of childbirths occurring in health facilities has increased dramatically over the past 10 years, this has not led to expected improvements in maternal mortality because health facilities have been unable to provide quality services, particularly emergency care. Similarly, the diagnosis and treatment of communicable andnon-communicable diseases, and ensuring psychosocial health and well-being, requires well-equipped, comprehensive and appropriate care at all levels of the health system, which is grossly inadequate today. If these gaps are not addressed, a mere improvement in existing indicators will be meaningless. The National Health Policy 2017 does call for strengthening of primary care in the form of developing “health and wellness centres”, but the poor financial outlays for health seem inconsistent with this ambitious vision.

Access to essential medicines:Although India is one of the leading manufacturer of pharmaceuticals in the world, it is estimated that over 65 percent of its population does not have access to essential medicines[5]. In this scenario, the fact that the National Health Policy 2017 has reinforced the idea of free medicines and diagnostics for all in Public Health facilities, is a good development. However, this is achievable if central Government funding is available instead of this being left entirely to the states. Another positive development has been price control of essential medicines which is being done through the Drug Price Control Order 2013. However, this covers only 15% of the total domestic market of more than Rs. 1 lakh crores.[6]Meanwhile, theNITI Aayog has advocated restricting price control and delinking it from the list of essential drugs, whereas the need of the hour is to extend the coverage of price control to more essential and life-saving drugs.[7]The NITI Aayog has also recommended disinvestment of government owned pharma companies, a move that will rob the Government of a vital tool to promote affordable access to medicines.[8]

Reining in the Private Health Care Sector:India’s large and unregulated private sector continues to operate without proper strictures, but policy developments indicate an unwillingness to take effective measures in this regard. Even as the Clinical Establishments Act remains unimplemented, the National Health Policy 2017 talks of “strategic purchasing”, which indicates a push towards privatisation. The Government of India’s VNR report states “Towards achieving universal health coverage, a health insurance cover of INR 100,000 (USD 1,563) is being extended to all poor families” – even though evidence suggests that the impact on financial protection has been minimal if not detrimental. Irregularities in the private sector which are evident in publicly funded insurance schemes such as the Rasthriya SwasthyaBimaYojana show that, there is an urgent need for regulation.[9]Attainment of targets such as the elimination of communicable diseases requiresthe private sector to comply with treatment guidelines and reporting requirements.In 2012, India started the web-based reporting system –Nikshay for implementing a policy of mandatory TB notification. Yet, despite the progress made, India still needs to track one million missing cases of TB annually, especially in the private sector. With growing threats of infectious diseases, it is imperative that private providers comply with reporting requirements.

Sabka Saath, Sabka Vikas:The SDGs recognize that gross inequities exist within and between countries, and have therefore emphasized the principle of “leaving no one behind”. In a large, unequal and diverse country such as India, this takes on even greater significance. The Government of India’s VNR report too states that the slogan of “Sabka Saath, Sabka Vikas” underpins its development efforts. However, nowhere in the report are inequalities examined, or analyzed. For instance, the report cites the reduction in Infant and Under-5 Mortality Rates over the past decade but fails to mention that child mortality rates among scheduled castes and scheduled tribes are higher than other groups.[10]“Leaving no one behind” implies reaching out to neglected populations using different strategies to address their unique concerns. For instance, even though there is a rise in institutional child births (which the GoI report mentions as one of the achievements of the last decade), one in four deliveries in rural areas still occur at home, and these have been systematically neglected. Disrespectful treatment of women, especially those from marginalized communities, during childbirth has been reported from various parts of the country, but is not acknowledged as a problem.

Despite overwhelming evidence of disparities in indicators, the GoI has not published recent disaggregated data on these. In fact, three rounds of the Annual Health Survey, conducted in high-focus states with the expressed purpose of contributing to meaningful tracking of progress towards MDGs, have not published any kind of disaggregated data. The same mistake is being made with the SDGs; none of the indicators, across targets are disaggregated and this will render it impossible to track progress of marginalized communities towards the goal.

Reporting, Transparency and Accountability: Tracking progress towards the SDG targets will require a robust and reliable monitoring system, as well as a strong accountability mechanism, both of which are currently lacking. Several of the indicators proposed by MOSPI are premised on the assumption that reliable data will be available; however existing discrepancies in data belie this assumption. For instance, according to the Global Burden of Disease Study report, India had 196,000 new cases of HIV infection in 2015 whereas the report by NACO states that there were 86,000 new cases of HIV in the same year. Establishing accurate and robust data systems is only a critical first step. Ultimately, it is the manner in which the data is used to determine problems, identify risks, develop strategies, set targets, allocate resources and fix accountability that will matter. A lack of transparency and will to seriously implement such accountability measures, has been a significant barrier, as demonstrated in case of maternal health, where although monitoring and accountability mechanisms like Maternal Death Reviewsexist, they are opaque and have yet not been fully operationalized.In addition to accountability within the system, social accountability and monitoring by community actors should also be ensured.

Conclusion

Despite the claims in Government of India’s VNR report, unless fundamental concerns around the organizing, financing and delivery of health care services are addressed, these efforts will remain as token measures. A fund starved, poorly equipped, non-transparent and unaccountable health system cannot be expected to fulfil the ambitious targets that the SDGs have set. Learning from the experience of the MDGs, it is therefore critical that these long standing concerns be addressed with urgency.